Published 10/20/2026
At a Glance
- AAOS supports the bipartisan Protecting Approved Care Act to curb Medicare Advantage clawbacks.
- The legislation would require Medicare Advantage plans to honor prior coverage determinations.
- AAOS argues the bill would improve financial stability for physicians and patients.
Estimated read time: 2 minutes
Last month, AAOS welcomed the introduction of the Protecting Approved Care Act, new legislation that addresses retroactive reimbursement changes from insurers (also known as clawbacks) in the Medicare Advantage (MA) program. This bipartisan bill, introduced by Reps. Greg Landsman (D-OH) and Bob Onder (R-MO), amends the Medicare statute to require MA organizations to honor original coverage decisions and puts safeguards in place to stop insurers from retroactively denying care or taking back payments already disbursed.
MA insurers routinely require physicians and patients to receive prior authorization (PA) before procedures and services are delivered. However, even when a procedure is approved (or when PA is not required), plans increasingly are retroactively denying coverage, reducing payments, or recouping payments that have already been sent to the MA organization.
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Related Content
- AAOS submits comment letter to CMS on Physician Fee Schedule (AAOS press release)
- AAOS firmly backs wide-sweeping prior authorization reform (AAOS Now)
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“The financial impact of clawbacks on our healthcare system cannot be understated,” said AAOS President Wilford K. Gibson, MD, FAAOS. “When insurance companies can shift coverage parameters after care is delivered, patients and physicians are left with unexpected financial burdens months or even years after a previously approved procedure or service is completed. Congress has the unique opportunity to hold insurers accountable by requiring MA organizations to honor their original prior authorizations.”
Modernizing Medicare Advantage
Data from the American Medical Association shows that 90% of physicians reported the PA process somewhat or significantly increases burnout. When insurers claw back an approval, it requires significant administrative work to resolve disputes. Physicians can also be forced to repay funds for services already delivered, adding financial strain.
The consequences are just as widespread for patients. MA patients may suddenly receive unexpected bills for care they thought was covered when the insurer unexpectedly pays less or refuses to pay at all. This particularly harms low-income seniors and people with disabilities who rely on MA, with 36% of enrollees reporting annual incomes of less than $25,000.
“As an orthopaedic surgeon, I’ve seen firsthand how clawbacks disrupt physicians’ ability to provide high-quality and timely care,” added Dr. Gibson. “The Protecting Approved Care Act will restore the integrity of the prior authorization system while increasing stability for physicians and patients.”